Junior Kindergarten - Please note -JK students may only register if they have completed the JK program.

Kindergarten

First

Second

Third

Fourth

Fifth

Please fill out all days in your child's schedule. (Days registered for, are days payment is required.)

5.

S.A.C. AM Session 6:00-8:00am

S.A.C. AM Session 6:00-8:00am

Monday

Tuesday

Wedneday

Thursday

Friday

6.

S.A.C. PM Session 2:45pm-6:00pm

S.A.C. PM Session 2:45pm-6:00pm

Monday

Tuesday

Wednesday

Thursday

Friday

7.

JK Wrap 7:45am-12:00pm

JK Wrap 7:45am-12:00pm

Monday

Tuesday

Wednesday

Thursday

Friday

8.

JK Wrap 10:45am-2:45pm

JK Wrap 10:45am-2:45pm

Monday

Tuesday

Wednesday

Thursday

Friday

9.

JK Wrap 7:45am-2:45pm

JK Wrap 7:45am-2:45pm

Monday

Tuesday

Wednesday

Thursday

Friday

10.

If your child needs transportation to and from JK Wrap please check the box yes.

If your child needs transportation to and from JK Wrap please check the box yes.

Yes

11.

*

Child's Starting Date

12.

*

I will give a two week notice if my child's main schedule changes and I will fill out the contract change form. Please initial below.

13.

*

Non-School day payment is $37.00. Flyers will be provided before non-school days. You must be pre-registered to attend. Would you like flyers for non-school day's?

Non-School day payment is $37.00. Flyers will be provided before non-school days. You must be pre-registered to attend. Would you like flyers for non-school day's?

Yes

No

Parent/Guardian 1

14.

*

Name Relationship

15.

*

Address Home Phone #

16.

*

Employer Work Phone #

17.

*

Cell # Fax # E-mail

Parent/Guardian 2

18.

Name Relationship

19.

Address Home Phone #

20.

*

Employer Work Phone #

21.

Cell # Fax # E-mail

22.

*

Who will be liable for child-care payment?

In case of an emergency and we cannot locate the parent/guardian, please call

23.

*

Name: Relationship:

24.

*

Address: Phone #

25.

*

Name: Relationship:

26.

*

Address: Phone #

All About Me! Please fill out child's infomation below:

27.

*

My favorite activity is:

28.

*

Do I have siblings:

Do I have siblings:

Yes

No

29.

Names of siblings

30.

*

My alleriges: Please state "none" if there are none.

31.

*

My medications: Please state "none" if there are none.

Staff will administer Tylenol/Ibuprofen with current medication permission form . Medication must be in original bottle.

32.

*

My Doctor's Name Clinic/Hospital Phone #

33.

*

My Dentist's Name Dental Office Name Phone #

34.

Insurance Company Policy #

35.

*

Do you have an IEP?

Do you have an IEP?

Yes

No

36.

*

Do you have special needs?

Do you have special needs?

Yes

No

37.

If yes, please explain.

38.

*

Do you have any restrictions at play?

Do you have any restrictions at play?

Yes

No

39.

If Yes, please explain.

40.

*

Do you have any additional Information to provide?

Do you have any additional Information to provide?

Yes

No

41.

If Yes, please provide.

42.

*

Parents/Guardians: Would you be interested in volunteering?

Parents/Guardians: Would you be interested in volunteering?

Yes

No

43.

Special Interests/Talents:

44.

*

I have read and filled out this form completely. I understand that should any changes in this contract occur, I will notify Somerset S.A.C./JK Wrap two weeks prior to changes. Contract change form is located online.

PARENT/LEGAL GUARDIAN SIGNATURE (By typing my name in this box I am verifying that I am the parent/legal guardian of the above mentioned participant. I am also verifying this electronic signature is approved and sent by me; the parent/legal guardian of participant.

The Transportation From MUST be completed in order for registration to be processed.
The form is located on the School Age Care home page under transportation.